Everything about melasma: causes, diagnosis, treatment and how to prevent relapses

Many people think that melasma consists only of some dark spots on the face.

However, today we know that it is a chronic and complex skin disease, in which hormonal, genetic, vascular, inflammatory and environmental factors are involved.

Melasma does not represent a risk to health, but it can have an important psychological impact and affect self-esteem.

Although there is currently no definitive cure, the vast majority of patients can achieve a very significant improvement with an appropriate treatment and a constant maintenance.

Melasma is an acquired alteration of the pigmentation characterised by the appearance of brown or greyish spots, generally symmetrical, in areas exposed to the sun.

The most frequent locations are:

• The forehead.
• The cheeks.
• The upper lip.
• The nose.
• The chin.

In some patients it can also affect the neck and forearms.

It is much more frequent:

• In women.
• Between 25 and 50 years of age.
• In people with phototypes III, IV and V.
• In people with a family history.

It can also appear in men, although with a much lower frequency.

Melasma does not have a single cause.

It is currently considered a multifactorial disease. Among the factors involved the following stand out:

• A genetic predisposition.
• Ultraviolet radiation.
• Visible light.
• Infrared radiation and heat.
• Hormonal changes.
• Pregnancy.
• Hormonal contraceptives.
• Hormonal therapy.
• Skin inflammation.
• Alteration of the barrier function.
• Vascular factors.

All this abnormally stimulates the melanocytes, the cells responsible for producing melanin.

Hormones play a very important role in many patients.

Melasma frequently appears:

• During pregnancy.
• After starting hormonal contraceptives.
• With some hormonal treatments.

However, many patients develop melasma without presenting any detectable hormonal alteration.

Although ultraviolet radiation remains one of the main triggers, today we know that:

• Visible light also participates.
• Heat favours pigmentation.
• Inflammation contributes to the maintenance of the disease.

For this reason some patients worsen even when using sunscreen correctly.

Spots generally appear:

• Light brown.
• Dark brown.
• Greyish in some cases.
• With poorly defined borders.
• Symmetrical.

They do not produce pain or itching.

The diagnosis is usually clinical.

Occasionally the skin health specialist may use:

• Dermatoscopy.
• Wood's light.
• Clinical photography for follow-up.

The biopsy is rarely necessary.

Yes.

It must be differentiated from:

• Solar lentigines.
• Post-inflammatory hyperpigmentation.
• Nevus of Ota.
• Ochronosis.
• Other pigmentary alterations.

Therefore a correct diagnosis is important before starting depigmenting treatments.

No.

This is one of the most important aspects that the patient must understand.

Melasma is a chronic disease with a tendency to reappear.

The objective of the treatment is to:

• Lighten the spots.
• Control the disease.
• Reduce the relapses.
• Maintain the improvement for as long as possible.

There is no single cream that works for all patients.

The treatment depends on:

• The depth of the pigment.
• The phototype.
• The intensity of the melasma.
• The skin type.
• The sun exposure habits.
• Pregnancy or breastfeeding.
• Previous treatments.

Different active ingredients can be used, among them:

• Hydroquinone (when it is indicated and during controlled periods).
• Azelaic acid.
• Topical tranexamic acid.
• Retinoids.
• Niacinamide.
• Vitamin C.
• Kojic acid.
• Cysteamine acid.
• Personalised compounded formulas.

The choice depends on each patient.

In carefully selected patients, oral tranexamic acid can be an effective therapeutic option.

It is not indicated for all patients and requires a prior medical assessment to rule out contraindications, especially those related to thrombotic risk.

Peels can help in certain cases.

However:

• They must be carried out by experienced professionals.
• A peel that is too aggressive can worsen melasma through post-inflammatory hyperpigmentation.

For years it was thought that the laser was the definitive solution.

We now know that it must be used with great caution.

Some devices can improve certain patients, but others can produce relapses or even worsen the pigmentation.

Energy-based treatment must be individualised and never replaces photoprotection or medical treatment.

Without good photoprotection it is very difficult to control melasma.

It is recommended:

• A broad-spectrum sunscreen SPF 50.
• Reapplication when necessary.
• A wide-brimmed hat.
• Seeking shade.
• Avoiding prolonged exposures.

In many patients, tinted sunscreens that incorporate iron oxides are also especially useful, since they help to protect against part of the visible light.

Frequently, yes.

It does not mean that the treatment has failed.

It simply reflects the chronic nature of the disease.

Therefore maintenance is as important as the initial treatment.

• Stopping the treatment on improving.
• Being exposed to the sun thinking that "it has already disappeared".
• Using home remedies.
• Carrying out aggressive peels without supervision.
• Buying depigmenting agents on the Internet without a diagnosis.

Although melasma does not represent a risk to health, many people experience:

• A decrease in self-esteem.
• Insecurity.
• Anxiety.
• Frustration due to the relapses.

Understanding that it is a chronic disease helps to maintain realistic expectations.

• Myth: Melasma is only a superficial spot. Fact: It is a complex disease in which multiple biological mechanisms are involved.
• Myth: Once removed, it will not come back. Fact: It has a tendency to reappear if the treatment and photoprotection are not maintained.
• Myth: The stronger the peel, the better. Fact: Treatments that are too aggressive can worsen the pigmentation.
• Myth: Sunscreen on its own eliminates melasma. Fact: It is essential, but it usually must be combined with specific treatments.
• Myth: All patients need the same treatment. Fact: The treatment must always be individualised.

• Melasma is a chronic pigmentary disease, not a simple spot.
• Ultraviolet radiation, visible light, heat and hormones play an important role.
• The treatment must be adapted to each patient and combine photoprotection with depigmenting therapies.
• Daily photoprotection is the fundamental pillar of the treatment.
• Relapses are frequent and do not mean that the treatment has failed.
• With an appropriate medical follow-up, most patients achieve a very important and lasting improvement.